A 11-year-old boy presented with sudden onset tender vesicular lesions on his face and neck, accompanied by redness and discharge from his right eye. He has a history of eczema since age 3. Examination found eczematous rashes with pustular and vesicular eruptions on his face and neck. He was diagnosed with eczema herpeticum with secondary impetigo and conjunctivitis. Treatment included antiviral and antibiotic medications, with referral to dermatology and ophthalmology. Eczema herpeticum is an acute herpes simplex infection in patients with atopic dermatitis that requires prompt treatment to prevent complications.

1. CASE PRESENTATION
Benedictus Widaja FY1
Awesomemedicalnotes.wordpress.com

2. HISTORY
 11 year old boy
 Known eczema since age of 3
 Presented with 1 day history of:
 Sudden onset tender vesicular lesions on right side of
face and neck. Burning sensation on face
 Redness on the right eye with some discharge
 Headache and vomiting 3-4x 1/7 ago but not on the day
of admission
 No fever or vomiting
 PMH:?infected eczema in the past. Discharged
from clinic in April.
 DH: epiderm BD & eumovate TDS

3. EXAMINATION

4. EXAMINATION
 Obs stable (T: 37.1, P 101)
 Alert, well-hydrated, not in distress
 Eczematous rash on face, neck, elbows, hands and
left ankle
 Pustular, vesicular eruption in clusters over right
side of face, neck and behind left ear. No lesion in
the ear
 Right eye – swollen lid margins, red conjunctive,
purulent discharge. No pain, normal eye
movements and reactive to light
 Otherwise normal

5. DIAGNOSIS
 Eczema herpeticum with secondary impetigo
 Right conjunctivitis
Impetigo

6. MANAGEMENT
 Admitted to ward
 Start IV aciclovir, Benzylpenicillin and Flucloxacillin
 Routine bloods + Herpes PCR
 Skin swab and eye swab for bacteriology and
virology
 Chloramphenicol eye ointment (d/w opthal reg)
 Referral to opthalmology and dermatology

7. DERMATOLOGY REVIEW
 Continue IV treatment for 1 week
 Doublebase emollient
 Paste bandages (viscopaste)
 Betnovate QC ointment to limb under viscopaste
bandages
 Chloramphenicol cream to face
 Vioform HC to face – not available, hydrocortisone
0.5% cream prescribed

8. RESULTS
 Swabs – staphylococcus aureus
 Blood culture –ve
 Routine bloods normal
 PCR – HSV DNA type 1/2 not detected

9. DISCHARGE
 Discharge with dermatology follow up in one week
 Oral aciclovir five times/day (total 10 days)
 Oral flucloxacillin 1g QDS (total 7 day)
 Phenoxymethylpenicillin 500mg QDS (total 7 days)
 Chloramphenicol eye drops QDS for 1 week
 Doublebase gel
 Hydrocortisone 1% cream BD
 Betamethasone valerate 0.1% ointment under
viscopaste bandages in the morning

10. ECZEMA HERPETICUM
 Acute disseminated herpes simplex infection, often
associated with systemic symptoms, in patients
with atopic dermatitis
 Commonly involve HSV type 1 or type 2
 Rarely vaccinia virus and Coxsackie A16 virus
 Infection may be from auto-innoculation or from
infected contact

11. CLINICAL PRESENTATION
 Multiple clusters of vesicles in areas of pre-existing
atopic dermatitis
 Spreading (to normal skin), haemorrhagic and
crusted
 Painful punched out erosions, which may coalesce
to form larger areas of erosions and crusting
 Majority of patients have fever and malaise
 Subclinical herpetic infection is quite common

12. PICTURES

13. PICTURES

14. PICTURES

15. IMPETIGO VS ECZEMA HERPETICUM
 Features that favour impetigo
 Honey-coloured crust
 Slower evolution
 Fewer systemic symptoms
 Features that favour eczema
 Punched out erosions

16. INVESTIGATION
 Swab for virology (PCR) and bacteriology from
fresh vesicle
 Other investigations:
 Bloods: FBC, biochem (CRP & albumin)
 Other tests to diagnose viral infection:
 Tzanck preparation
 Direct fluorescent antibody testing

17. MANAGEMENT
 Consider advising patient to discard previously used
emmolient (esp if it is stored in tubs) or creams if
contamination is suspected
 Initiate treatment on the same day (delay may increase
length of hospital stay)
 IV or oral aciclovir
 IV or oral antibiotics (flucloxacillin & benzylpenicillin) for
secondary bacterial infection
 Topical antibiotics cream if no evidence of bacterial infection
(rarely used in UK due to bacterial resistance)
 Topical opthalmic antiviral may be added if there is evidence
of periocular involvement (keratitis prophylaxis)
 Dermatology referral
 Opthalmology referral for periocular lesions

18. MANAGEMENT OF ECZEMA
Steroids from least to most potent:
Hydrocortisone, eumovate (clobetasone), betnovate (betamethasone),
dermovate (clobetasol)
Topical calcineurin inhibitor (tacrolimus) may be used on face if
hydrocortisone is not sufficient. The use of stronger steroids is not
recommended on face
Side effect of steroids: skin thinning, telangiectasia, adrenal suppression

19. PROGNOSIS
 Very low mortality with the availability of effective
antivirals
 Average duration of illness is 16 days, cases lasting
as long as 6 weeks have been reported.
 Recurrent episodes tend to be milder and are not
associated with systemic symptoms.
 Complications if untreated:
 Herpes hepatitis
 DIC
 Herpes keratitis, conjunctivitis
 In disseminated infection can involve brain, lung, GI and
adrenal

20. CONCLUSION
 Although potentially life threatening, if eczema
herpeticum is recognized early it is easily and
effectively treated.
 Any patient with history of atopic dermatitis and
acute "blistering" should be examined for eczema
herpeticum.

21. REFERENCES
 Royal college of paediatrics and child health allergy care
pathways for children eczema
 Aronson PL, Yan AC, Mittal MK, Mohamad Z, Shah
SS Delayed acyclovir and outcomes of children hospitalized
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Research Support, N.I.H., Extramural, Research Support,
Non-U.S. Gov't]
Pediatrics 2011 Dec; 128(6):1161-7.
 Brook, I., Frazier, E.H., & Yeager, J.K. (1998). Microbiology of
infected eczema herpeticum. Journal of the Academy of
Dermatology, 38, 627-629.
 Sais, G., Jucgla, A., Curco, N., & Peyri, J. (1994). Kaposi's
varicelliform eruption with ocular involvement. Archives of
Dermatology, 130, 1209-1210
 CG57 Atopic eczema in children: NICE guideline
 Mooney MA, Janniger CK, Schwartz RA. Kaposi's
varicelliform eruption. Cutis. 1994;53:243-245.